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Blood transfusion is often utilized in surgery. Greece is the second-highest consumer of blood components in Europe. It has been shown that at least half of all transfusions are unnecessary and could be avoided. Jehovah's Witnesses (JWs) are a Christian religion that do not accept transfusion of whole blood or the four primary components of blood-namely, red blood cells, white blood cells, platelets, and plasma. This a retrospective study from September of 2015 to January of 2018, analyzing all JWs who underwent an elective operation at the Second Department of Propaedeutic Surgery in Laiko University Hospital. Twenty-nine (Rogers et al. in NCCN Guidelines Version 2.2014 Cancer- and Chemotherapy-Induced Anemia. NCCN Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network, Fort Washington, 2013) JW patients, 23 females (74.1%) and eight males, were operated on during the aforementioned period. The median ASA score was 1 (range 1-3), and only two of the patients needed postoperative monitoring in the ICU. Almost half of the patients (45.1%) needed iron infusion and EPO injection preoperatively. Two patients presented with postoperative complications, with no postoperative deaths. In conclusion, we found that surgery, in our small group of JW patients, was safe and successful despite the lack of blood transfusion. Techniques developed to treat JW patients should be more widely used to improve clinical outcomes and reduce costs to the healthcare system.

Highlights • Entero-vesical fistulas (EVFs) represent an uncommon complication of Crohn’s disease. • EVFs affects mostly men patients. • Conservative treatment improves symptoms but is associated with low rate of healing. • Surgical approach is usually necessary, establishing long-term remission., Background Entero-vesical fistula (EVF) is an abnormal link between the enteric lumen and the urinary bladder. Crohn's disease (CD) represents, nowadays, the most common cause in the formation of this fistula. Materials and methods The aim of this study was to describe the diagnostic and treating modalities applied in nine patients with CD and EVFs, the clinical/epidemiological features of this clinical entity and to perform a systemic review of the literature, concerning the diagnosis and treatment of this complication. Results The medical records of eight men and one woman (mean age 42 ± 12 years) with EVFs were analyzed. The terminal ileum and the ileocecal region were affected in three and six cases, respectively. The most common symptoms were pneumaturia, fecaluria, fever, urinary urgency and abdominal pain. The diagnosis was suspected by abdominal CT scan and by indirect findings of bladder infection in cystoscopy. MRI with concurrent cystography set the diagnosis in three patients. Colonoscopy was not helpful. Conservative treatment, including administration of antibiotics and immunosuppressive agents in all patients and anti-TNF-a agent (infliximab) in six patients, was ineffective. Surgical treatment was applied in seven cases (77.8%), including fistula repair in all patients, drainage of coexistent intraabdominal abscess in two, small bowel resection in four and ileocecectomy in two cases. Conclusion EFVs are uncommon but potentially dangerous complications of CD. Abdominal CT scan and cystoscopy are the most commonly used diagnostic modalities. Surgical treatment seems to be unavoidable in most cases, although medical treatment could also benefit a small cohort of patients.

The purpose of this study was to investigate the effect of splenectomy on cellular immunity. We studied the cellular phenotype and type 1 [interferon-gamma, interleukin-2 (IL-2)] and type 2 (IL-4 and IL-10) cytokine-producing peripheral blood CD4+ and CD8+ T lymphocytes in 22 healthy adults who had undergone post-traumatic splenectomy about 1 to 35 years ago. Splenectomy resulted in a long-term reduction of the percentage of CD4+CD45RA+ cells and a late increase of the percentage and absolute numbers of T-cell receptor gamma/delta cells. Stimulation with Staphylococcal enterotoxin B resulted in normal IL-2 production by CD4+ T cells, indicating that the naïve cells were not anergic. Splenectomy also resulted in long-term priming of both CD4+ and CD8+ T cells. During the first 8 years, both type 1 and type 2 CD4+ T cells were primed to varying degrees. About 8 years later, the percentage of primed type 2 CD4+ T cells subsided, but that of type 1 CD4+ T cells, although decreased, remained detectable over a longer period. Priming of CD8+ T cells persisted throughout the study period. The long-term priming of type 1 CD4+ and CD8+ T cells, which may result in partial impairment of T-cell functions, may explain reported defects of immune responses to recall antigens in splenectomized individuals. In addition, changes in the profile of primed CD4+ T cells with time may be clinically relevant to relapses in autoimmune thrombocytopenia after splenectomy.

Background: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. Methods: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial which has started in September 1997. In 24 hospitals in Sweden, The Netherlands, Germany, France, Italy and Spain, 1,200 patients will be included. The primary end point of the study is cancer-free survival after 3 years. Results: Within Conclusions: Although laparoscopic surgery appears of value in colorectal malignancy, results of randomized trials have to be awaited to determine the definitive place of laparoscopy in colorectal cancer. Considering the current accrual rate, the COLOR study will be completed in 2002.

This is an experimental study in rats, examining bacterial translocation and endotoxemia in obstructive jaundice, as well as the protective effect of lactulose, an endotoxin-binding agent. Four groups

Mycotic artery aneurysms are rare but potentially lethal vascular lesions due to their high risk of rupture. Bacterial endocarditis as well as trauma and inadequate immunity are predisposing factors. Surgery remains the treatment of choice, although alternative methods have been used. We report the first known case of a 6 cm mycotic splenic artery aneurysm proximal to the splenic hilum, secondary to bacterial endocarditis from Coxiella burnetii . Resection of the aneurysm, splenectomy, and distal pancreatectomy were performed. In all patients with culture-negative endocarditis and mycotic aneurysm, C. burnetii infection should be ruled out.

Human and pig cystic and pig hepatic arteries were suspended in tissue baths and the effect of alpha-adrenoceptor selective drugs, prostaglandin F2 alpha (PGF2 alpha) and vasopressin were investigated. Prazosin fulfilled the criteria for competitive antagonism in concentrations 10(-9)-10(-7) M. The pA2-values were 9.53 in human cystic, 9.74 in pig cystic, and 9.57 in pig hepatic artery. Rauwolscine had no significant effect in the different arteries. In human cystic artery noradrenaline had significantly (P less than 0.05) higher Emax and pEC50-values (135% of the preceding K(+)-induced contraction and 6.4, respectively) compared with pig cystic (106% and 5.7, respectively) and pig hepatic artery (116% and 5.9, respectively). Vasopressin had no effect in the cystic arteries, whereas it had a high potency (pEC50 was 8.5) but low intrinsic activity (Emax was 14%) in pig hepatic artery. Prostaglandin F2 alpha had a significantly higher Emax in human than in pig arteries. No differences were found in pEC50-values. This study indicates a similarity in pharmacological characteristics of some vasoactive drugs especially between pig cystic and hepatic arteries. If this is also true in man, the easily obtainable cystic artery can be used for screening the effect of drugs on the hepatic artery.

SummaryPost-traumatic splenectomy is associated with increased postoperative morbidity and mortality and long-term impairment of humoral and cellular immunity. Alternatives to surgery have been developed to minimize or avoid the immediate and/or long-term complications of splenectomy. Herein we investigated the long-term effect of non-operative management (NOM) of the traumatic rupture of the spleen on the distribution of peripheral blood (PB) lymphocyte populations and cytokine production by T cells. PB samples were drawn from six NOM patients, 13 age-matched adults who had undergone splenectomy after trauma (SP patients) and 31 age-matched controls. Cellular phenotypes and the intracellular production of interferon (IFN)-γ, interleukin (IL)-2, IL-4 and IL-10 cytokines in T cells were determined in whole blood ± mitogens by flow cytometry. NOM patients did not show any changes in the absolute numbers of lymphocytes or the distribution of their subsets, compared to the controls. In contrast, SP patients showed a sustained increase in the percentage and/or absolute numbers of lymphocytes, CD8 T cells, activated CD8 T cells, natural killer (NK) T cells, NK cells and γδ T cells, and a reduction in naive CD4 T cells. The constitutive or induced cytokine production by T cells of the NOM group was similar to the control group, whereas SP patients had increased percentages of constitutive IL-2- and IFN-γ-producing CD8 T cells and IFN-γ-producing CD4 T cells. Our findings indicate collectively that the healing process in NOM does not affect the architecture of the spleen to such an extent that it would lead to long-term alterations of the proportions of PB lymphocytes or the T cell cytokine profiles.

Despite considerable improvement in the diagnostic and therapeutic approach to patients with acute upper gastrointestinal (GI) bleeding, several studies suggest there has been no overall change in mortality. The aim of this study was to evaluate prospectively the effect of early emergency diagnostic and therapeutic endoscopy and medico-surgical collaboration in the clinical outcome of 1534 patients with acute upper GI bleeding treated in our hospital over the past five years. Emergency endoscopy and injection haemostasis were performed within 24 hours of admission, or immediately after resuscitation, in patients with massive bleeding; patients were then treated with close co-operation between surgeons and gastroenterologists. We observed an increase in the incidence of peptic ulcer (67%) with a simultaneous decrease in the incidence of gastroduodenitis (13.5%) as a cause of bleeding compared with the previous decade. In peptic ulcer bleeding, emergency surgical haemostasis was required in 92 patients (8.9%), while none of the patients with erosive gastroduodenitis required surgical intervention. Overall mortality was 2.9%, and in peptic ulcer bleeding patients 2.1% with a postsurgical mortality of 8.7%. Peptic ulcer remains the main cause of upper GI bleeding. Improved clinical outcome and low mortality can be achieved with early diagnostic and therapeutic endoscopy and medico-surgical collaboration.

It has been noticed that patients undergoing major lung resection may occasionally develop dysphagia. A prospective study was carried out to evaluate if preoperative or postoperative esophageal motility disorders (EMD) occur in patients subjected to pneumonectomy for lung carcinoma. Twenty-five normal volunteers served as control data and 13 patients, who successfully completed manometry before and after pneumonectomy, were included in the final analysis. Studies were performed using a Gaeltec Model 6 ct/sb, 6-channel intraluminal strain gauge transducer probe. Our results demonstrated that EMD occurred in some patients suffering from lung carcinoma. However, motility disorders were most evident following pneumonectomy. These findings may explain the several anecdotal reports of patients developing dysphagia following lung resection after a variable interval of time.

We report a case of early presentation of a hepatocellular carcinoma with obstructive jaundice, due to obstruction of the common bile duct by a blood clot. The possibility of preoperative diagnosis, the surgical treatment and the postoperative outcome are discussed.

Les anevrysmes mycotiques arteriels sont des lesions vasculaires rares mais potentiellement mortelles en raison de leur a haut risque de rupture. L’endocardite bacterienne comme le traumatisme et un deficit immunitaire en sont facteurs favorisants. La chirurgie demeure le traitement de choix, bien que des methodes alternatives aient ete employees. Nous rapportons le premier cas connu d’un anevrysme mycotique de 6cm de l’artere splenique en amont du hile splenique, secondaire a une endocardite bacterienne a Coxiella burnetii. La resection de l’anevrysme, la splenectomie, et la pancreatectomie distale ont ete realises. Chez tous les patients presentant une endocardite a culture-negative et un anevrysme mycotique, une infection a C. burnetii devrait etre eliminee.

Six pigs were used to study whether the collection of shed blood by means of surgical compresses instead of suction traumatizes such blood. In an in vivo part of the study, the whole blood volume of the pigs was retransfused after treatment with citrated compresses, and in an in vitro part the blood was treated extensively with compresses and analyzed. All animals survived, with a minor fall in hemoglobin after 48 hours and a rise in serum citrate concentration at the end of the experiment. A study of the coagulation system revealed no important change after retransfusion of compress-treated blood. In the in vitro part of the study, repeatedly squeezing blood from the compresses increased the concentration of free hemoglobin to a maximum of 5 g/l after ten squeezes, whereas platelets were numerically unchanged. The study indicates that collecting shed blood by means of surgical compresses may be a safe and efficient method.

The liver and plasma level of the lysosomal enzyme beta-hexosaminidase was analyzed in partially (about 70%) hepatectomized rats with normal liver or carbon tetrachloride (CCl4)-induced cirrhosis. The enzyme level of the liver did not show marked changes after partial hepatectomy in either normal or cirrhotic rats. In contrast, the plasma basal level was significantly higher in cirrhotic rats and increased to a peak at 6 h, followed by a decrease to a minimum level 24 h after operation. The enzyme returned to its high plasma basal level at 36 h after partial hepatectomy, when the liver had recovered to 70% of its initial weight. In rats with normal liver the plasma beta-hexosaminidase showed another pattern, with a rapid increase at 6 h and thereafter gradually reaching a peak at 36 h after hepatectomy. We conclude that the cells responsible for increased plasma beta-hexosaminidase in cirrhotic rats are situated in the liver.

The effect of intraportal infusion of norepinephrine (NE) on primary hemostasis in the cirrhotic rat was investigated at standardized liver trauma. Cirrhosis was induced by simultaneous administration of increasing amounts of carbontetrachloride (CCl4) and phenobarbitone. Infusion of norepinephrine took place after cannulation of the gastroduodenal vein. Intraportal infusion of NE resulted in a significant increase in arterial blood pressure and portal pressure in all animals. No difference was observed between cirrhotic and control rats. Cirrhotic animals bled longer and more profusely as compared with the controls. Infusion of NE resulted in significant decrease in bleeding time and blood loss. NE did not affect hematocrit, hemoglobin, platelet, or white cell count. Platelet aggregation was not influenced by the compound. In conclusion, intraportal infusion of NE proved effective in decreasing hemorrhage at liver trauma in cirrhotic rats.

The effect of intraarterial, intraportal or simultaneous intraarterial and intraportal norepinephrine (NE) infusion on hemorrhage after standardized liver trauma was evaluated in the rat. Infusion of NE through a catheter in the gastroduodenal artery or/and vein, was started 5 min prior to the liver trauma and continued throughout the experiment. Blood pressure was continuously registered after cannulation of the femoral artery. Standardized liver trauma involved resection of the left anterior liver lobe. Bleeding time, blood loss from the traumatized liver surface, hemoglobin (Hb), hematocrit (Hct), platelet count (PC) and white blood cell count (WBC) were measured. Infusion of NE resulted in significant increase of blood pressure compared with controls. Infusion of NE (i.a., i.p., i.a. + i.p.) caused significant decrease in bleeding time and blood loss. Hb, Hct, PC and WBC were not affected. NE infusion proved effective in decreasing hemorrhage at liver trauma; the route of administration did not influence the results.

Thirty rats were subjected to a standardized critical aortic injury and divided into six groups. In addition to controls, the animals were treated with a pneumatic antishock garment (PASG), massive intravenous or intra-aortic saline infusion, or PASG in combination with either massive intravenous or intra-aortic saline infusion. Twenty-six rats were subjected to a standardized hepatic injury and divided into four groups. In addition to controls, the animals were treated with PASG, massive intravenous saline infusion, or PASG in combination with massive intravenous saline infusion. These animals were allowed to bleed for 5 minutes before the treatment was started. The treatment with PASG alone prolonged the median survival time significantly from 7 min in the control group to greater than 120 min in the PASG group in rats with an aortic injury and from 33 to greater than 120 min in rats with a hepatic injury. Intravenous infusion of saline did not prolong the median survival time. Intravenous infusion in combination with PASG did not have any positive effects on median survival time or median mean aortic pressure and failed to prolong the median survival time significantly in rats with a liver injury, as six out of eight animals developed a lethal pulmonary edema.

Background Cancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non‐operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice. Discussion In deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient‐related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour‐related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital‐related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra‐operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down‐staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear‐cut evidence of irresectability.

The effect of the simultaneous administration of norepinephrine and 5-fluorouracil (5-FU) on the uptake of radiolabelled 5-FU by liver tumours was studied in rats. Three different concentrations of 5-FU were used (15, 1.5 and 0.15 microgram/g body weight). The drugs were infused over a 30 min period via the hepatic artery, following cannulation of the gastroduodenal artery. The radioactivity in liver tumour, normal liver, lungs and intestines was estimated by liquid scintillation counting. At all concentrations tested, an increased uptake of radioactive 5-FU was found in the tumour when norepinephrine was infused. Tumour/liver ratios also increased significantly in all these cases. No significant differences were noted between norepinephrine infused and control animals in the radioactivity in normal liver, lungs and intestines. The effects noted were possibly due to changes in blood flow within the liver, but the possibility of a direct effect of norepinephrine on DNA metabolism is discussed.

Increased brain serotonin metabolism has been suggested as an etiologic factor in the development of portal-systemic encephalopathy (PSE) in connection with liver disease. We therefore investigated brain serotonin metabolism and open-field behavior (spontaneous activity and exploration) in rats with carbon tetrachloride (CCl4)-induced liver cirrhosis. Brain serotomin metabolism was evaluated in rats pretreated with an amino acid decarboxylase inhibitor. The 5-hydroxyindoles were analyzed by high-performance liquid chromatography (HPLC) with electrochemical detection. The results revealed an increased serotonin synthesis rate in all investigated brain regions in rats with histologically verified diffuse micronodular cirrhosis of the liver. Slightly impaired open-field behavior (i.e., decreased spontaneous activity) in the cirrhotic rats could not be excluded. However, the elevated brain serotonin synthesis rate could not be correlated to any abnormalities in open-field behavior.

It is generally accepted that early and specialized pre-hospital patient treatment improves outcome in terms of mortality and morbidity, in emergency cases. The focus of this paper is to present the implementation and the evaluation of an ambulance located telemedicine system for pre-hospital patient treatment The primary emphasis is on the vital sign transmission from the accident site or the moving ambulance to the consultation site, using the GSM mobile telephony network. There, the experts evaluate the patient data, decides about the treatment protocol and provide directions to the ambulance's medical staff concerning on the patient handling until the arrival to the hospital.